Modification of the African American Women’s Stress Scale: A Validity and Reliability Study

1. Modification of the African American Women’s Stress Scale:A Validity and Reliability Study Cynthia Bienemy, PhD, RN Southern University and A & M College Graduate Nursing Programs Alumnus of the Substance Abuse and Mental Health Services Administration Fellowship Program at the American Nurses Association Email: cynthiabienemy@suson.subr.edu

2. What is Stress? Stress Is:“A negative emotional experience accompanied by predictable biochemical, physiological, cognitive, and behavioral changes that are directed either toward altering the stressful event or accomodating to its effects”.Taylor, 2003, p. 179

3. Stress results from the process of appraising events as harmful, threatening, or challenging, of assessing potential responses, and of responding to those events based on an individual’s internal and external resources.Lazarus & Folkman, 1984; Taylor, 2003

4. Chronic Stress Chronic stress has been defined as ongoing demands which are appraised by individuals as being taxing or exceeding their available resources and endangering themselves and their family’s wellbeing. Lazarus & Folkman, 1984; Watts-Jones, 1990

5. Chronic stress has been found to be a precursor to both physiological and psychological illnesses in African American women, a segment of the U. S. population that is affected by high rates of poverty and an increased prevalence of chronic diseases. Greenburg, Stiglin, Finkelstein & Berndt, 1993; Murdaugh, 1990; Webb & Becksted, 2002

6. Research findings have revealed that African Americans are exposed to more extreme socio-environmental stressors than whites, and they also tend to show greater cardiovascular and sympathetic reactivity to such stressors. Alexander et al., 1996

7. African American Women: • Live in a majority dominated society that often devalues their ethnicity, culture and gender • Find themselves at the lower spectrum of the American political and economic continuum • Are involved in multiple roles as they attempt to survive economically and advance themselves and their families • Have one of the highest rates of cardiovascular mortality and morbidity in the developed world • Report more depressive symptoms than African American men or Caucasian men and women Carrington, 1980; Danquah, 1998; Porter, 2001; Webb & Beckstead, 2002; Warren, 2001, 1997;

8. Problem Statement There is a paucity of gender and culturally specific research instruments which can be used to evaluate the influence of chronic stress-related variables on the development and control of specific physiological and psychological illnesses in African American women.

9. Purpose of the Study • To determine the validity of an instrument which was modified to measure chronic stress in a sample of 167 African American women (The African American Women’s Stress Scale- Modified Version). • To determine the reliability of the modified version of the African American Women’s Stress Scale in a sample of 167 African American women with a clinical diagnosis of high blood.

10. The African American Woman’s Stress Scale • The African American Women’s Stress Scale (AWSS) is a 100 item self-report inventory that represents an attempt by Dr. Dee Watts-Jones to develop a valid stress scale for African American women (AAW). • A major assumption of the AWSS is that AAW provide the best source for identifying meaningful and relevant stressors in their lives and determining how stressful they are in their experience. • Nearly half of the stressors on the original AWSS reflected chronic situations, while the remaining stressors represent acute stressors or life events. Watts-Jones, 1990

11. Modification of the AWSS • The investigator for the current study was interested in examining relationships between chronic stressors, high blood pressure and depressive symptomatology in African American women. • Permission to modify the AWSS to reflect chronic stressors was obtained from the author of the original 100 item AWSS.

12. Modification of the African American Women’s Stress Scale:A Validity Study • Concept analysis on the concept ‘chronic’ • Two levels of Expert Validity • Expert Panel – Determination of the content validity index (CVI) • Concurrent Analysis • Construct Validity - Factor Analysis

13. Concept Analysis • Purpose – to objectively define the concept ‘chronic’ in order to appropriately select items pertaining to ‘chronic’ stressors from the AWSS. • Defining Attributes – ongoing, lasting a long time, lingering, continuing, negative effect, intense • Antecedents – person(s); ongoing situation originating from physiological, psychological, sociological, economical, cultural and/or spiritual origin; no cure or means to correct the situation can be identified by the person(s) • Consequences – inability to function effectively; demands exceeds coping mechanisms; stress; anxiety, depression, physical illness/co-morbidites; economic stagnation, death/suicide

14. Two Levels of Expert Validity • Dr. Watts-Jones agreed to participate in the validation study by serving as an expert in the selection of items from the original AWSS which reflected chronic stressors • The investigator also participated in the selection of chronic stressors from the original AWSS using the findings obtained from the concept analysis of ‘chronic’. • Only those chronic stressors that were chosen by both Dr. Watts-Jones and the investigator were selected for further validation by a panel of experts (45 proposed chronic stressors).

15. Expert Panel • Psychiatrist - 10 Years Exp. • Obstetrician/Gynecologist - 17 Years Exp. • Professor Emeritus – 40+ Years Exp. as faculty and obstetric/gynecological nurse practitioner • Social Worker (Mental Health Substance Abuse) – 5 Years Exp. • Family Practice Physician – 24 Years Exp.

16. Content Validity Index • The experts were asked to rate each of the 45 potential chronic stressors on a scale from 1 to 4 describing the extent to which they agreed that the item indeed represented a potential chronic stressor in the lives of AAW. • The content validity index (CVI) was calculated for each of the items. • Items having a CVI between .80 and 1.00 were included in the modified AWSS (23 items). • The 23 items were placed on a 5-point Likert scale which addressed the intensity of the stressor

17. Sample Population – 167 African American WomenCommunity Based Recruitment

18. Demographics: n=167 African American Women • Age Study Participants National Average* Mean Age 50.2 Years • Marital Status Married 44% 38% Single 23.5% 38.2% Separated/Divorced 23.5% 12.9% • Education Completed High School 97.7% • Employment Fulltime 60.8% 61.8% Unemployed 16.3% 10.2% • Yearly Income $9,999 or less 21.5% 14.7% $10,000 - $29,000 28.8% 30.7% $30,000 - $39,000 16.6% $40,000 - $49,000 8.6% $50,000 or More 24.5% 32.1% *U.S. Census 2003; 2000 Census of Population and Housing

19. Concurrent Validity • The Perceived Stress Scale (PSS), a measure of global stress, is one of the most widely accepted instruments used to measure stress (Cohen, 1994). • The PSS and the AWSS (Modified) were administered on the same day to the same group of AAW in order to determine concurrent validity for the modified version of the AWSS. • Findings - A significant positive correlation was found between the two measures of stress: Pearson’s rp-valueN .266 .001** 167

20. Construct Validity:Results of the Factor Analysis on the Modified Version of the AWSS

21. Reliability of the Modified Version of the African American Woman’s Stress Scale

22. Reliability Coefficients: Cronbach’s alpha

23. Reliability Coefficient: Cronbach’s alpha

24. Additional Findings obtained with the Modified Version of the African American Woman’s Stress Scale (AWSS-Modified)

25. Relationships Between Chronic Stress, SBP and DBP *p<.05; **p<.01

26. Relationships Between Chronic Stress and Depressive Symptoms *p<.05; **p<.01

27. Summary of Major Findings • The modified version of the African American Woman’s Stress Scale was found to be • a valid measure of chronic stress in AAW • a reliable measure of chronic stress in AAW • a potentially more gender and culturally sensitive measure of chronic stress in African American women

28. Limitations of Study • Lack of generalizability of research findings due to: • Non-randomized convenience sampling technique • Potential participant bias related to self-report measures

29. Recommendations for Further Study • Conduct further studies using the AWSS (Modified) as a measure of chronic stress in larger samples of African American women having various chronic physiological and psychological illnesses. • Design an intervention study which addresses the impact of chronic stressors on the prevention and treatment of chronic physiological illnesses (i.e., blood pressure) and psychological illnesses (i.e., clinical depression).

30. Implications for Nursing Research, and Nursing Practice Chronic stress may be a key under-researched variable when developing interventions addressing the health care needs of African American women who are at risk for, or who have been diagnosed as having certain physiological and psychological illnesses.Pickering, 2000

31. This Study Was Funded In Part By:  Southern University and A & M College School of Nursing Nursing Doctoral Fellowship Program Baton Rouge, LAThe Substance Abuse and Mental Health Services Administration Ethnic Minority Fellowship Program at the American Nurses AssociationWashington, DCThe American Association of University WomenBaton Rouge Branch

32. Thank YouFor Your Attention!Question/Answer Session